Diagnosing Melanoma


Source: NCCN











Getting A Second Opinion




When You Should Consider a Second Opinion


  • Your diagnosis was made by a doctor without expertise in melanoma
  • Your doctor gives you several different treatment options
  • You don’t feel that all possible treatment options have been explored
  • Your doctor does not offer clinical trials
  • Your doctor recommends that you seek a second opinion
  • Your treatment plan involves aggressive treatment

How to Get a Second Opinion


  • The American Society of Clinical Oncology (ASCO) allows the public to search for member oncologists through its Cancer.net website

Insurance Coverage



The Doctor’s Examination

Here is what to expect when you schedule a visit to your doctor after detecting skin changes:

Complete Medical History

The doctor will first take a complete medical history to learn about your symptoms and risk factors. You will be asked your age, when you first discovered the area of concern on your skin, and if any features of that area have changed since your discovery. The doctor will ask about past exposures to known causes of skin cancer, such as sun exposure. You will also be asked whether you or your family have a history of atypical moles or skin cancer, particularly melanoma.

Complete Skin Examination

You will be asked to undress completely and be given a gown. The suspicious mole or lesion will be evaluated with the naked eye for size, shape, color, texture, and any evidence of bleeding, oozing, or scaling. The doctor will then perform a thorough and systematic examination of the rest of your body to check for other spots or moles that may be related to your skin cancer. This will include scalp, nails, palms, soles, ears, and areas not exposed to the sun, including beneath the breasts or under any rolls of flesh.

Lymph Node Evaluation

The doctor will palpate (feel) the lymph nodes nearest the suspicious lesion, (in the groin, or underarm, or neck). If the nodes are enlarged or unusually firm, additional tests may be recommended to evaluate whether cancer has spread to the regional lymph nodes.

Skin Biopsy

A doctor who suspects that a skin spot is melanoma will perform a biopsy. In this procedure (usually performed with a local anesthetic to numb the area), the doctor removes the suspect lesion using techniques that preserve the entire lesion so that the thickness of the potential cancer and its margins (healthy tissue around the lesion that is removed to make sure no cancer cells remain) can be carefully examined.


Any skin samples taken during a biopsy are sent for microscopic examination, and a pathology report is issued by the pathologist. If it is diagnosed as melanoma, the pathology report describes many aspects of the cancer, including; the size, the thickness of the lesion, the mitotic rate, the presence or absence of ulceration, lymphatic response, regression, satellite lesions, and blood/nerve invasion.

Other Tests for Melanoma

Doctors use many tests to diagnose melanoma and determine if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. The doctor may order various tests to determine if or where the melanoma has spread.

Your doctor may consider these factors when choosing a diagnostic test:

  • Your age and medical condition
  • The type of cancer
  • Severity of symptoms
  • Previous test results

Standard Diagnostic Tests:

  • Blood tests: No special blood tests are needed for localized melanoma and there are no reliable ones that can indicate specifically whether or not a melanoma has spread. Testing for elevated levels of LDH may indicate the presence of metastatic disease.
  • Chest x-ray: It is taken to make sure melanoma has not spread to the lungs, the lymph nodes in the mediastinum (space in the chest between the lungs), or the bones of the rib cage.
  • CT scan: A CT scan of the chest, head, abdomen, or pelvis, may be recommended if it is suspected that the melanoma has spread. A rotating x-ray beam takes a series of pictures of the body from many angles. A computer combines the information from all the pictures and makes a detailed, cross-sectional image of the body. Except for possible minor discomfort from the injection of intravenous dye to highlight certain tissues in the body that may otherwise be hard to see, this is a painless procedure.
  • MRI (magnetic resonance imaging): Like the CT scan, MRI is only used when it is suspected that the melanoma has spread. It may be recommended in place of a CT scan. The major difference is that the cross-sectional images of the body are created by magnetic fields instead of x-rays. MRI is particularly useful for looking at the brain, spinal cord, and examining specific areas in the bone. It may also be used if the results from other imaging tests are unclear or there is a concern about exposure to radiation.
  • PET scan (positron emission tomography): For a PET scan, radioactive glucose (a form of sugar) is injected into the body. Cancer cells usually absorb glucose more quickly than normal cells, so they may light up on the PET scan. However, since a number of normal body activities also use large amounts of glucose, false-positive results are fairly common and their results should be verified by other tests. Newer devices combine PET and CT scans.


Skin Biopsy

If the physical examination shows evidence of a suspected melanoma, your doctor will recommend a skin biopsy, a procedure to remove all or part of the mole for evaluation under a microscope.

The biopsy provides important information:

  • Whether the mole is benign or malignant
  • If malignant, how deeply the tumor has penetrated the skin and whether there are associated signs of ulceration

A skin biopsy is quick and about as uncomfortable as having blood drawn. The physician will clean the area to be biopsied with alcohol and then inject a small amount of local anesthetic. Because the anesthetic makes the skin swell and has a low pH, it burns for about 5 to 10 seconds. It is similar to the anesthetic used by dentists. Once the anesthetic has taken effect, the doctor will use a scalpel, a razor blade, or a small circular blade called a “punch” to free a small piece of skin. Because the skin is numb, the patient can feel pressure but no pain during this part of the procedure. If a deep biopsy is taken, 1 or 2 stitches are used to close the wound. If the biopsy is superficial, the wound is left open to heal like deep scrape. The whole process usually takes about 5 minutes. Often, skin samples are sent to a dermatopathologist.


Types of Biopsies

Different methods can be used to do a skin biopsy. Doctors will choose the type of biopsy depending on the size of the affected area and the location on the body.

Excisional Biopsy

The doctor cuts out the entire suspicious lesion. This is the preferred method for small lesions.

  • Description: Typically, this would happen in the doctor’s office as an outpatient procedure, under a local anesthetic.
  • What you’ll feel: You will feel a needle stick and about 10 seconds of burning when the doctor anesthetizes the lesion. Once the spot is anesthetized you may feel pressure, but no pain from the surgery as the doctor cuts though the skin and removes the tumor. The doctor finishes by sewing the wound together.
  • How long does it take? The procedure usually takes less than an hour.
  • Afterwards: Some over-the-counter pain medication will ease any pain coming from the site of the surgery. You’ll probably need a return visit for the doctor to remove stitches and check your healing.

Incisional Biopsy

The doctor may recommend taking just a portion of the lesion. This may occur because the lesion is too large for an excisional biopsy, or because taking it all would destroy important tissue, as on the face or hands, or leave scars.

  • Description: Incisional biopsies are performed in the doctor’s office under local anesthetic. One type, called a punch biopsy, uses an instrument that resembles a tiny, round cookie cutter with a diameter of 3, 4, or 6 millimeters (1/8″, 1/6″, or 1/4″). Incisional biopsies can also be made with a scalpel which will give you a more elliptical wound.
  • What you’ll feel: While it is a surgical procedure, you won’t experience much pain. You’ll feel a needle stick and a little burning with some pressure when you receive the anesthetic. But as it takes effect, you won’t feel any pain from the surgery as the doctor removes a portion of the lesion with the tool. The doctor finishes by sewing the wound together.

Superficial Shave Biopsy

This is a process used for superficial skin disease when a deeper tissue cut is not required, such as melanoma in situ, skin tags or seborrheic keratoses.

  • Description: In a shave biopsy, the doctor numbs the area with a local anesthetic and then “shaves” off the top layers of the skin (the epidermis and a part of the dermis) with a surgical blade.
  • What you’ll feel: A needle stick and a little burning with some pressure when the anesthetic is injected. It is usually about as uncomfortable as having one’s blood drawn. Once the anesthetic takes effect, you may feel pressure, but no pain, as the physician shaves off of the top layers of skin.
  • Superficial Shave Biopsies are DISCOURAGED for suspected melanomas other than melanoma in situ.
    • Suspected melanomas require biopsies of the full thickness of the skin and underlying fat.
    • Superficial shave biopsies may not go deep enough to give an adequate tissue sample in order to determine tumor depth, ulceration or mitotic index.
    • Other superficial techniques such as freezing and cauterizing tissue samples are also not recommended, for similar reasons.

Deep Shave Biopsy (Saucerization)

This biopsy technique is like a superficial shave biopsy, but is used to obtain a deeper specimen and is often used when biopsing lesions suspected of being melanoma.

  • Description: Saucerization procedures are performed in the doctor’s office under local anesthetic. A doctor uses a surgical blade to “scoop out” the suspicious lesion, and a sufficient depth of skin beneath it to be able to stage the cancer.
  • What you’ll feel: While it is a surgical procedure, you won’t experience much pain. You’ll feel a needle stick and a little burning with some pressure when you receive the anesthetic. But as it takes affect you won’t feel any pain from the surgery as the doctor removes a portion of the lesion. The wound is not usually sewn closed, but is left to heal from the inside out.
  • How long does it take? The procedure usually takes less than 10 minutes.
  • Afterwards: Some over the counter pain medication will ease any pain coming from the site of the surgery.


What to Ask Your Doctor Before a Biopsy


Diagnosis Questions Your Notes
What information do you hope to gain from the biopsy?
What is the likelihood that the biopsy will establish a diagnosis?
Can the diagnosis be established by any other methods?

Treatment Questions Your Notes
How is the biopsy done?
Is the procedure painful? Is a local or general anesthetic involved?
How safe is the biopsy procedure?
Can the biopsy be performed in your office or must the procedure be done in a hospital?
Will you be removing the entire lesion or a part of the lesion? Why?
How many samples will be removed?
How large is the tissue fragment to be removed?
How long will the procedure take? Can I go about my normal daily activities afterward?

Side Effect Quesetions Your Notes
Will I have pain or scarring afterward?
Will I need stitches?
How do I take care of the biopsy site?
What should I do if I think I have an infection?
What does an infection at a biopsy site look like?
Are there any complications that might arise as a result of the biopsy procedure?

If complications develop, what should I do or whom should I contact?

You Should Also Ask Your Notes
Who will explain the results of the biopsy to me?
How long will I wait until a result is available?
How will I be informed about the result of the biopsy?



Skin samples taken by a biopsy or surgical excision are typically sent to a pathologist/pathology laboratory for microscopic examination and diagnosis. A pathology report is issued by the pathologist or dermatopathologist. The pathology report states the diagnosis and further describes many aspects of the appearance of the melanoma, including the type, depth of invasion, tissue level of invasion, presence or absence of a lymphatic response, presence or absence of ulceration, mitotic count, presence or absence of regression, presence or absence of satellite lesions, and presence or absence of blood vessel/lymphatic vessel/nerve invasion.

Additionally, the pathology report will describe whether the excised lesion is a primary melanoma, in which case it would be described using the terms above, or a metastatic melanoma deposit. A metastatic melanoma deposit is one in which the melanoma started somewhere else on the skin and some of the melanoma cells broke off and spread within the skin tissue to the current biopsy/specimen site.

Some Terms You May See on Your Pathology Report

Type of Melanoma (Histologic Subtype):

  • Superficial spreading melanoma
  • Nodular melanoma
  • Acral lentiginous melanoma
  • Lentigo melanoma
  • Desmoplastic melanoma
  • Other: mucosal melanoma
  • Other: uveal melanoma

Breslow Depth: Measurement in millimeters of how thick the primary tumor is, regardless of its Clark Level. It is measured from the top layer of the skin to its deepest point.

Clark Level: Clark Level was replaced in the revised melanoma staging system in 2010 by more reliably predictive features (mitotic count and ulceration). It is now only used to stage thin melanomas (< 1mm).

Radial Growth Phase (RGP): The melanoma lesion is described as either having RGP present or absent. If present, RGP is an indication that the melanoma is growing horizontally, or radially, within a single plane in the upper/superficial skin layers (mainly in the epidermis).

Vertical Growth Phase (VGP): The melanoma is described as either having VGP present or absent. If present, VGP is an indication that the melanoma is growing vertically, or deeper, into the tissues.

Tumor-Infiltrating Lymphocytes (TILs): TILs describe the patient’s immune response to the melanoma. When the pathologist examines the melanoma under the microscope, he/she looks to see whether or not there are lymphocytes within the melanoma. The amount of lymphocyte invasion/response to the melanoma is described as brisk (a lot of lymphocytes), nonbrisk (some), sparse (few) or absent (none), although occasionally it can be described as mild or moderate. TILs appear to indicate that your immune system has recognized the melanoma cells as abnormal and is trying to move into the melanoma to attack it. Some studies suggest that the presence of increasing number of TILs may be associated with a better prognosis.

Ulceration: Ulceration is described as being present or absent. It is the breakdown or loss of the top layer of cells in a melanoma and often occurs in the center of a tumor. The presence of ulceration increases the stage classification of a melanoma. Ulceration is thought to reflect rapid tumor growth, leading to the death of cells in the center of the melanoma and thus is associated with a worse prognosis. The pathologist can determine whether ulceration is present or absent when they review the biopsy under the microscope.

Regression: Regression is described as an area of the tumor without active melanoma cell growth and is described as present or absent. If it is present, the extent of regression is estimated.. When regression is present, the measured thickness of the melanoma may not be the greatest/true thickness.

Mitotic Count (Mitotic Rate): Mitosis is the process by which one mature cell divides into two identical cells. When pathologists study a melanoma, they will count the number of actively dividing cells that they see. Averaging this number gives the mitotic count and it is reported as the number of mitoses per square millimeter (mm2), (example ≤1 mitoses/mm2). A high mitotic count means more tumor cells are dividing at a given time, and is associated with a worse prognosis.

Satellites: Satellite lesions are small nodules of tumor/melanoma located more than 0.05mm from the primary lesion, but less than 2cm. Satellites are described as being present or absent. Some satellite lesions (macroscopic) can be seen with the naked eye. Others, which are smaller (microscopic) can be found only by the pathologists. Both macroscopic and microscopic lesions are reported in the pathology report.

Blood Vessel/Lymphatic Invasion: Blood vessel invasion, also called angioinvasion, or lymphatic vessel invasion, is described as being present or absent. If present, it means that the melanoma has invaded the blood or lymph system and is associated with more aggressively growing melanomas.


Sentinel Lymph Node Biopsy (SLNB)


The Importance of The Lymph Nodes

Once the skin biopsy has been done and it has been determined that you have melanoma, the next step is to establish whether or not the melanoma has spread beyond the primary tumor or local tissues.

The presence or absence of melanoma cells in the lymph nodes is one of the most important prognostic factors we have, since it indicates what the melanoma might do in the future as well as the type of treatment you may need.

The Role of The Sentinel Lymph Node Biopsy (SLNB)

SLNB is a specialized procedure done to determine whether any melanoma cells have spread to the sentinel nodes. If the melanoma has spread, it will usually spread to the lymph nodes nearest the area of the primary melanoma. The sentinel lymph nodes are the first of those lymph nodes to receive drainage from the primary tumor, and therefore the ones most likely to have melanoma cells if any of them have spread.

When a SLNB IS Indicated

  • Melanoma is equal to or greater than 1.0mm
  • Ulcerated tumors of any thickness
  • Positive margins
  • Lymphovascular Invasion (seeing cancer cells in the lymphatic channels or blood vessels)
  • Mitotic rate (rate at which cells divide) in young adults

When a SLNB IS NOT Indicated

  • Melanomas less than 0.76mm with no other risk features
  • It is already known that melanoma is in the lymph nodes (Stage III)
  • It has spread to distant organs (Stage IV)

How the SLNB is Done

The SLNB has two parts, a radiology test called lymphatic mapping, and a surgical procedure. A wide local excision should also be performed at the same time.

  • Lymphatic Mapping (Lymphoscintigram) usually involves injecting radioactive dye in the skin around the site of the original melanoma. Then a special camera is used to watch the radioactive material move from where the melanoma was biopsied to the group of lymph nodes the melanoma is most likely to travel to first. These are called the sentinel nodes and in most patients there are between 1 and 5 sentinel nodes.
  • Surgery is performed after the lymphatic mapping has been completed. You will generally receive a second agent (blue dye) that will help visually identify the lymph nodes that have already been detected using the special camera. This two-method approach is more accurate than using either one alone. The surgeon will remove the sentinel nodes and they will be examined by a pathologist under a microscope. It will take several days to get the results.
  • Wide Local Excision is a procedure in which the melanoma, including the biopsy site as well as an area of normal tissue around it (margins), is removed. It is recommended that lymphatic mapping and the sentinel lymph node biopsy be performed before the wide local excision is done.

After The Surgery

The sentinel nodes removed by your surgeon will be examined under a microscope by a dermatapathologist to determine if there is melanoma in the lymph nodes. It has been found that approximately 17% of patients have melanoma in their lymph nodes.

  • If the sentinel lymph nodes do not show cancer, then it is unlikely that the cancer has spread to the other lymph nodes and no further surgery is necessary.
  • If it is shown that there is melanoma in the lymph nodes but no where else in the body, then the remaining lymph nodes in that area are removed. This is called a complete lymph node dissection. (CLND)

Note: The survival rate of patients is markedly better when the melanoma in the lymph nodes has been found by means of a SLNB, as opposed to being found during a physical exam.


Determining the Stages of Melanoma


The TNM Staging System

The TNM System (Tumor-Node-Metastasis) is the most widely used way of determining cancer stages. This staging system, created by the American Joint Committee on Cancer (AJCC), provides important prognostic and survival information. A number of clinical and pathological factors determine the stage of melanoma.

T for Tumor

The “T” categories are given numbers (0 to 4) based on the tumor’s thickness. The tumor may also be assigned the letter “a” or “b” based on ulceration and mitotic rate.

  • TX: Tumor cannot be evaluated.
  • T0: Zero evidence of cancer.
  • Tis: Melanoma is “in situ” meaning it is still in the outer layer of skin and has not grown into other layers, and shows no signs of spreading.
  • T1: The primary tumor is 1.0mm or thinner and one of the following:
    • T1a: There is no ulceration and the mitotic count is less than 1mm2.
    • T1b: There is ulceration or the mitotic count is equal to or greater than 1mm2.
  • T2: The primary tumor’s thickness is between 1.01mm and 2.0mm and one of the following:
    • T2a: There is no ulceration.
    • T2b: There is ulceration.
  • T3: The primary tumor’s thickness is between 2.01mm and 4.0mm and one of the following:
    • T3a: There is no ulceration.
    • T3b: There is ulceration.
  • T4: The primary tumor is thicker than 4.0mm and one of the following:
    • T4a: There is no ulceration.
    • T4b: There is ulceration.

N for Nodes

The “N” classification tells you if melanoma cells have moved from the primary tumor into nearby lymph nodes. Melanoma cells that are found along the lymphatic vessel but have not yet entered a lymph node are called “in-transit metastases” or “satellites.” The number of lymph nodes to which the cancer has spread is important. When more lymph nodes have melanoma, there is reason for greater concern.

  • NX: Regional (in the area near the melanoma primary site) lymph nodes cannot be evaluated.
  • N0: No evidence of spread to the lymph nodes.
  • N1: The melanoma has spread to 1 lymph node and one of the following:
    • N1a: The doctor cannot feel cancer in the lymph nodes but can detect the cells when a sample is taken (microscopic metastasis).
    • N1b: The doctor feels cancer in the lymph node or can see it on a scan (macroscopic metastasis).
  • N2: Melanoma has spread to 2 or 3 lymph nodes and one of the following:
    • N2a: The doctor cannot feel a tumor in the lymph nodes but can see melanoma cells in a lymph node sample under the microscope (microscopic metastasis).
    • N2b: The doctor can feel the tumor in the lymph nodes or see it on a scan (macroscopic metastasis).
    • N2c: The doctor finds in-transit metastases or satellites without finding metastatic nodes.
  • N3: Any of the following conditions:
    • The melanoma has spread to 4 or more lymph nodes.
    • Two or more lymph nodes appear joined together (called matted lymph nodes).
    • In-transit metastases or satellites are present, with any number of metastatic lymph nodes.

M for Metastasis

The “M” classification tells you if melanoma cells have moved from the primary (original) site to distant sites in the body, and where in the body they have moved to. The seriousness of the melanoma depends on where it has spread (metastasized). Usually, metastasis is associated with more advanced stages of cancer.

  • MX: Distant metastasis cannot be evaluated.
  • M0: The melanoma has not spread to distant sites.
  • M1a: The melanoma has spread outside the region where it first started to other parts of the skin, under the skin, or any distant lymph nodes.
  • M1b: The melanoma has spread to the lungs.
  • M1c: The melanoma has spread to any other internal organ in the body other than the lungs and the LDH is normal OR there is distant spread to any site and the LDH is elevated.


What to Ask Your Doctor About Your Melanoma Diagnosis


Diagnosis Questions Your Notes
What stage of melanoma do I have?
Will I need additional tests or procedures to confirm the stage of my melanoma?
Did the surgery remove all of the melanoma?
Were there concerning features on the biopsy such as ulceration or high mitotic rate?

Treatment Questions Your Notes
What treatment plan do you recommend? Why?
Do I need additional surgery?
Do I need additional treatment?
What are the side effects of this treatment?
What type of follow-up will I need?
What are clinical trials? Would any be appropriate for me?
What is my prognosis?
Should I get a second opinion?

You Should Also Ask Your Notes
How often should I go for a skin exam?
What are the chances of my melanoma recurring?
What are the chances of developing a new melanoma?
What can I do to reduce my risks of developing another melanoma?
What is the risk of my family members developing melanoma?


Dealing with the Diagnosis

When your doctor tells you that you have cancer, it can often be overwhelming. However, it is important that you and your caregiver learn as much about your diagnosis as you can, in order to give you the ability to make the best decisions possible.

Knowing the right questions to ask your doctors, deciding whether or not to get a second opinion, and seeking out information about your diagnosis and options, are all ways of helping you take control and determine the treatment plan that is best for you.